Serious sequelae of maxillofacial infections

Numerous complications are attributed to maxillofacial infections, including Ludwig’s angina, mediastinitis, cerebral abscess, maxillary sinusitis, chronic fistulous tracts and infective endocarditis.These may result from a delay in adequate treatment of the original focus of infection, and may turn a minor problem into one with dangerous complications. Infections in the sublingual or submandibular space are not contained by any anatomical barriers and may spread to the mediastinum or diaphragm via the contiguous fascial spaces of the neck.1

Ludwig’s angina is defined as bilateral cellulitis of the submandibular and sublingual spaces.2 The adult mortality rate from the disease is reported to be between 4% and 10%.3 Ludwig’s angina has the potential to spread rapidly, resulting in mediastinitis and airway obstruction.2,4

Common clinical features of odontogenic infections (which may progress to cause significant maxillofacial infections) are summarised in Box 2. An OPG may reveal evidence of odontogenic infection. Other investigations, such as CT scans of the jaws and neck and blood investigations (eg, full blood count, electrolytes/urea/creatinine levels, procalcitonin level [an indicator of infectious processes] and blood cultures), may be ordered if clinically indicated. Clinical signs warranting prompt hospital referral include dysphagia, difficulty with or pain on moving the tongue, stridor, trismus, elevation of the tongue, and fever.

It is inadvisable to treat these patients only with analgesia and antibiotics, as surgical drainage of the abscess or removal of the focus of infection is also required.5 An otherwise well patient with no systemic signs of infection, cellulitis or airway compromise does not require antibiotics once the source of the infection has been eliminated. With respect to odontogenic abscesses, this may involve extraction of the offending tooth or teeth, with drainage via the extraction socket, or may require intraoral and/or extraoral drainage. If the patient’s medical condition allows it, and if dentally suitable, the responsible tooth or teeth may be endodontically treated, allowing the patient to retain the tooth.

Options for airway management include awake fibreoptic intubation, creating a surgical airway (tracheostomy or cricothyroidotomy), inhalational induction with blind nasal intubation under deep anaesthesia, and awake blind nasal intubation.6

When indicated, antibiotics that cover the expected mixed anaerobic and aerobic nature of oral infections should be chosen. Suitable choices include intravenous ampicillin (1 g four times a day) together with metronidazole (500 mg three times a day).5 For patients allergic to penicillin, clindamycin is a possible alternative. The regimen should be modified in response to culture and sensitivity results.

Suppurative salivary gland infections are often caused by Staphylococcus aureus, for which treatment with dicloxacillin or flucloxacillin is appropriate.